The survival rates of adolescent and young adults with cancer have risen dramatically due to advancements in cancer therapies.However, this population is at an elevated risk of chronic treatment-related sequelae such as fatigue and secondary cancers as well as psychosocial issues that include fear of recurrence or poor self-esteem. There is a growing consensus that adopting and maintaining a healthy lifestyle can help mitigate some of these detrimental effects. In this installment of The ASCO Post’s Integrative Oncology series, Emily S. Tonorezos, MD, MPH, summarizes the research evidence on the impact of lifestyle changes in young adult cancer survivors.

With ongoing improvements in diagnosis, treatment, and supportive care, the number of adolescent and young adult cancer survivors is growing.1,2 However, these survivors are at a risk of several chronic medical and psychosocial sequelae, some of which may be ameliorated through healthy behaviors. They include maintaining a normal weight; eating a high-quality diet; being physically active; and limiting the use of tobacco, alcohol, or drugs.3-8 Consequently, promoting a healthy lifestyle is being increasingly recognized as a critical component of high-quality survivorship care for young adults.

Changes in Poor-Quality Diet and Sedentary Behavior

Multiple studies indicate that young adult cancer survivors are often overweight or obese and that a poor-quality diet or sedentary behavior are common.9,10 Although young adults are typically active, cancer diagnosis, treatment, and recovery can be detrimental to exercise behavior.11 A longitudinal study of 97 teenagers and young adults with cancer found that activity levels declined during treatment. Furthermore, upon completion of treatment, nearly 25% of these patients were sedentary, despite being active before their cancer diagnosis.12

Emily S. Tonorezos, MD, MPH

Current evidence on how best to support or enable lifestyle changes for this population is limited. Factors such as self-efficacy (defined as confidence in one’s ability to change a behavior) and social support (especially peer support) are likely to be important. In a qualitative study of 13 survivors (mean age, 22.9 years), interest in information about healthy diet and physical activity was found to be high; and social support appeared to help bring about changes in health behavior and self-efficacy.13 This population also often has access to social media and is likely to be aware of trends in commercial diet and physical activity interventions.14 Yet survivors wonder whether these options are safe or indicated after cancer treatment.

Another cross-sectional survey (n = 118) was conducted to determine the applicability of the transtheoretical model’s stages of change (starting with precontemplation and contemplation) to physical activity or a healthy diet. Investigators found that self-

Promoting a healthy lifestyle is being increasingly recognized as a critical component of high-quality survivorship care for young adults.

— Emily S. Tonorezos, MD, MPH

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efficacy, knowledge of strategies for behavior change, and supportive family or friends were associated with a readiness to change.15

The type of physical activity or dietary intervention that will work best for young adults also remains undetermined. Some evidence suggests that technology-based distance interventions may be best suited for this age group.16 A review of lifestyle technology-based interventions among childhood, adolescent, and young adult cancer survivors detailed the results of six studies demonstrating high retention rates, acceptability, and feasibility. Physical activity interventions had overall positive effects on motor performance—but not on daily physical activity, fatigue, or quality of life. However, due to small sample sizes and short duration of studies, the sustainability of the positive effects was deemed difficult to assess.17 Nonetheless, available evidence suggests that young adult survivors are interested in healthy diet and physical activity and have the ability to make changes given strong social support and self-efficacy.18

Tobacco, Drugs, and Alcohol

Despite the associated risks, young adult cancer survivors use tobacco, drugs, and alcohol at rates that are similar to their peers.19,20 One hypothesis is that the so-called teachable moment, which is used to engage older cancer survivors, may not be relevant for this population.21 However, young adults cite a cancer diagnosis as an underlying reason for their interest in lifestyle-related information and attempts to change lifestyle.13 Peer-group normative behavior, social support for tobacco and alcohol use, and low self-efficacy for healthy behaviors are also highly relevant. Indeed, as the previously described qualitative study13 revealed, lack of social support, self-efficacy, and self-confidence were identified as barriers to adopting a healthy lifestyle.

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Clinical assessments of tobacco cessation interventions are limited. In a randomized controlled trial conducted by Emmons and colleagues, 796 survivors who smoked received a self-help tobacco cessation intervention with or without peer counseling, along with written educational materials and free nicotine replacement therapy. At 8 and 12 months, and at a later follow-up at 2 and 6 years, cessation rates were significantly higher in the peer counseling group than in the group that received a self-help intervention (20.6% vs 17.6%).22,23 A separate study, conducted by the same group and involving 374 survivors, compared a Web-based intervention with printed self-help materials. Tobacco cessation rates were reported to be the same in both groups (16%).24 These results strongly suggest that peer support is important for successful tobacco cessation—and likely other healthy behaviors—in this population.

With regard to cannabis and alcohol use, only one study of a substance use decision aid in teen cancer survivors has been published, and the impact of the intervention was modest.25 Current estimates place cannabis use at 10% to 12% among young adult cancer survivors,20,26 whereas alcohol use and binge drinking are more common.27 The changing landscape of the availability of cannabis and legality of use will certainly impact its use. Notably, knowledge regarding the impact of cannabis smoking on pulmonary function and respiratory health is evolving as well.28

Recommendations

Young adult cancer survivors are at risk of late effects of cancer therapy that could be ameliorated by healthy diet; physical activity; and avoidance of tobacco, drugs, and alcohol. Many studies show that this group is interested and motivated toward leading a healthy lifestyle. Yet the lack of social support and poor self-efficacy have significant impact on behavior modification. Providers hoping to support a healthy lifestyle in this population should seek interventions where these concepts are salient. ■

Dr. Tonorezos is a general internist in the Adult Long-Term Follow-up Program at Memorial Sloan Kettering Cancer Center, New York.